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FOR OFFICE USE; <br /> ------------------------------------------- ------------- <br /> ­------------------ ---------------------- ------------- <br /> ------------.------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. .� �� <br />-----------------------•----------------- --------------- (Complete in Duplicate) <br /> ------- --- This Permit Expires 1 Year From Date Issued Date Issued __A -� <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the worst- § r "ed. <br /> This application is made in compliant with Count Ordinance No. 549. _ <br /> JOB ADDRESS AND O TION ._ _. <br /> -- <br /> Owner's Nome = ---------- Phone.. <br /> ---•---•------------ <br /> Address �t�r `� 4 � ................................................................. <br /> Address <br /> Name. --------------------------------------------------------------------- Phone........................ ... <br /> Installation will serve: Residence ❑ Apartment-House ❑ Commercial ❑ Tra'lerI ❑ Motel [3 Other <br /> Number of living units: -------- Number of bedrooms -------- Number of ba+hsj________ Lot size ----- -- •-...•-.._-.---!----- <br /> Water Supply: Public system E] Community system ❑ Private ❑ Depth TO Water Table. -�ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes El ElFHA/VA: Yes ElNo ElTYPE OF INSTALLATION AND SPECIFICATIONS: <br /> 19 <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well.�6_.......Distance from founclation_.,Z d_. Mateol__ - --__...•_•.............. <br /> No. of compartments__ ..___- .f5ize_, x,$`,� --•_-.Liquid depth___��1 -------Capacity-.24C�- <br /> Disposal Field: Distance from. nearest well <br /> k5_0 k5_�_____.Distance from foundation__Zd..........Distance to nearest lot line............... <br /> Number of lines...... Length of each line-------- ' Width of trench-___ _ .. __ .1----------------- <br /> Type of filter materiaL �- epth of filter material------,--- <br /> ________Total length---------______________�7� -`.r___._ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-_..----------------Distance to nearest lot line............. <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----•-----------------_Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining material-------------------------- <br /> p q P -------------------------gals. <br /> } ------- Depth Liquid Capacity_Size: Diameter__________________________._ <br /> Pr.ivy: Distance from nearest well-----------------------------------.----- -------Distance from nearest building_____.___-._________--.-- <br /> 7 ❑ Distance to nearest lot line <br /> Remodeling and/or repairing (describe):-------------- ----------------------------••--------•----•-•-------------------------•---•-•--..... <br /> •---------•--------------------------------------•--------------- ------------•------------------------------------------------------------- --------------- <br /> -----------------•----- ---•---------------•-------•-------•----•-----------•---------•--------•---------------------------------------•-••------------•------------------•--••--••-------•------------•------•------ <br /> I hereby certify t 1 have prepared this application and that the work will be done in accordance with San Joaquin County' <br /> ordinances, State bws and rules d regulati of the S -n Joaquin Local Healthy District. <br /> (Signed)-------•• ---- -•�------- --- -- ---- -------- ------ ---------- -- --- ---- - --•---------- - ( wrier and/or Contractor) <br /> By:-------------------------------------------------------------------------------- - - - ------- --------- ---------- - --- --(Title)----------- ---- --r•-•-----------._....----------------------- <br /> (Plot plan, showing size of lot, location of system in relati to wells, buildings, c., can be placed on reverse side). <br /> —FOR"DEPARTMENT USE-ONLY �- <br /> APPLICATION ACCEPTED BY---- us_ � DATE <br /> ,� ------- <br /> _71.1 -�-�---------- <br /> ---------------- <br /> REVIEWED BY-------------------------------------------------- ----------------------------------------------•-----------------------•--.- DATE <br /> BUILDINGPERMIT ISSUED------••--•-•---------------------------___------------------------_----------------------- DATE <br /> Alterations and/or recommen"d'ations:--------•----------------------------------- --------- <br /> ----------------------------•----------------•-- <br /> ----- ..... ------ <br /> ------ --- ---- --------------•-------------------------------------------------------------. ---- <br /> -_ - ` R <br /> ............................... ---------------- .: ry <br /> FINAL INSP TION BY: ---- -- Date----- ---- �..W.�?_�..__... <br /> SAN.JOAQ�UIN LOCAL HEALTH DISTRICT <br /> 4 730 South American Street 300 West Oak Srreet r 124 Sycamore Street 205 West 9th Street <br /> « Stockton,California Lodi,California Manteca,California Tracy,California <br /> ES 9' REVISED 8-59 2M 5-62 ATLAS v <br />